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S oaquin County Public Health Se w Environmental Health Division '`f ,� Medical Waste Management Program J APPLICATION FOR A LIMITED QUANTITY HAULING EXEMPTION To qualify for a "Limited Quantity Hauling Exemption" pursuant to the "Medical Waste Management Act', the following conditions must be met: The generator or health care professional generates less than 20 pounds of medical waste per week, transports less than 20 pounds of medical waste at any one time, maintains a tracking document pursuant to Chapter 6, and the generator or parent organization has on file one of the following: 1- Medical Waste Management Plan if the generator or parent organization is a large quantity generator or a small quantity generator required to register pursuant to Chapter 4. 2- Information Document if the generator or parent organization is a small quantity generator not required to register pursuant to Chapter 4. PLEASE COMPLETE THE INFORMATION BELOW AND MAIL WITH $67 FEE TO: San Joaquin County Public Health Services Environmental Health Division Medical Waste Management Program P.O. Box 388 Stockton, CA 95209-0388 Medical Waste Hauler Information ❑ New ❑ Renewal Medical Office/Business Name: Dameron Hospital Association Medical Office/Business Address: 525 West Acacia Street City: Stockton State: CA Zip Code: 95203 Contact Person: Mark G. Koenig Phone* (209)944-5550 Storage Facility Name: -same- Storage Facility Address: City: State: Zip Code: Permitted Treatment Facility Name: -same- Permitted Treatment Facility Address: City: State: Zip Code: List all employee names and titles authorized to transport the medical waste. If not enough space, attach information. -See attached listing-- 1- Name: Title: 2- Name: Title: 3- Name: Title: A copy of this exemption and a tracking document all be in employee's possession at all times while transporting medical waste. In addition, all copies of medical s n:co s shall ke gn file at gendratoes or health care professional's facility. Applicant Signature: Title:Safety Officer Date: 12 / 23 / 96 Do Not Write Below This Line R.E.H.S. Application Approval: qL, Date: / //D/4?-Expiration Date: EH4502 10-03-96 Date Paid ,_O/ / D9 /97 Cash or Check ` qOJ a (circle) Acct tA.